Heart Failure Nurse Navigator- Downtown ORL

At Orlando Health Heart and Vascular Institute, our renowned cardiologists, heart and vascular surgeons, and cardiovascular professionals work together to provide award-winning care in 40 specialties, using the latest in diagnostic imaging and treatment options. Our multidisciplinary team includes more than 70 physicians in 24 locations across Central Florida, spanning Orange, Osceola, Lake, Seminole, Highlands and Okeechobee counties. As a part of Orlando Health, the Heart and Vascular Institute includes a network of community and specialty hospitals with more than 4,000 providers.

Leverages best practices and evidence-based guidelines to deliver high quality, efficient, consistent, and coordinated care to patients diagnosed with heart failure, in collaboration with multidisciplinary clinical teams and partnered organizations and services.

Compile and analyze data used to identify hospitalized acute and chronic heart failure patients, and distribute such patient lists to other departments to encourage data consistency and promote multidisciplinary collaboration. Provide detailed and contemporary education and discharge materials tailored specifically to patient needs via booklets, videos, classes, and other channels, as necessary, to educate heart failure patients, their families, and their caregivers. Demonstrate the highest levels of compassion, nursing skill, and technical competency in all patent interactions. Establish and maintain a positive working relationship with patients to foster patient engagement and drive treatment compliance. Document patient care in a knowledgeable, skillful, and consistent manner meeting all required and regulatory standards. Perform assessments of patient needs, available resources, precipitating factors, and educational opportunities to develop/revise individualized care plans, and to evaluate patient progress toward attaining expected outcomes. Determine and anticipate post-acute patient needs, including services such as home health support, durable medical equipment, and REACH Team/Social Services to maximize care outcomes across the care continuum. Serve as an advocate for the patient, collaborating with cross-functional and multidisciplinary teams, to enable high quality and reliable care transitions and access to medications. Act as the principal facilitator between Orlando Health and contracted vendors to improve the longitudinal care for heart failure patients, including coordinating with the paramedicine program team, leveraging remote patient monitoring solutions, and connecting patients with palliative care services, as necessary, among other such programs. Coordinate with the Heart Failure Clinic to ensure patients are scheduled for follow up appointments post-acutely, either for virtual or in-person care, to reduce the likelihood for re-hospitalization. Coordinate telephonic or virtual visit outreach to all heart failure patients within three days of discharge from the hospital to assess their clinical progress, evaluate their understanding of the condition, verify follow up appointments are calendared, and encourage healthy behaviors and medication adherence. Actively participate in program-specific collaborative opportunities, including multidisciplinary rounds. Serve on, or actively engage with, related quality and readmission task forces, and regularly attend corporate and site-specific heart failure collaborative sessions, including AHA “Get with the Guidelines” sessions, SNF/DON collaborative meetings, and Corporate Heart Failure CC team building sessions. Collaborate with appropriate outlying facilities and agencies to ensure protocols are aligned with evidence-based guidelines. Understand the principles of growth and development over the life span and/or disease state and implement interventions, as appropriate, while being sensitive to cultural needs and patient preferences. Communicate appropriate information regarding patient condition or unit concerns to other health care team members. Exhibit respect to patients and families by showing awareness of legal issues and patients’ rights, consistently providing a safe and clean care environment, and ensuring all other safety, health, and regulatory standards are satisfactorily met and satisfied. Prioritize patient care in an ongoing manner in accordance with Evidence-Based Practice Standards of Care. Perform all other duties as assigned. Maintain reasonably regular, punctual attendance consistent with Orlando Health policies, the ADA, FMLA and other federal, state and local standards. Maintain compliance with all Orlando Health policies and procedures. Other Related Functions Proficient in building interpersonal relationships through the use of excellent communication skills and team building strategies. Practice effective problem identification and resolution utilizing evidence-based practice. Respect diversity by building respectful relationships with all team members and customers. Partner with the nursing leadership team to identify professional development needs. Comply with all regulatory and accrediting requirements.